Blepharoplasty Enquiry Form ↓ Home › Blepharoplasty Blepharoplasty YOUR DETAILSFirst Name *Last Name *Email Address *WhatsApp Number *TREATMENT GOALS & CONCERNSWhat are your expectations and concerns? (Select all that apply) *Double eyelids / lack of creaseDesire for larger or more defined eyesImpaired vision due to excess skinPuffy or swollen eyelidsHeavy eyelids / discomfortTearing or lacrimal gland protrusionnoneOther, please specifyAny other relevant medical history, chronic conditions, current medications, or known sensitivities that may affect your treatment. Please specify:Have you had any previous cosmetic or surgical procedures in the eye (periorbital) area? *noyesPlease provide details: (Type of procedure, approximate date, clinic/doctor, any complications or outcomes) *PHOTO UPLOADPlease upload clear, recent images taken in good natural light. Face the camera directly and avoid makeup, filters and contact lenses where possible.(Files: jpg | png | gif, not larger then 1 MB)1. Eyes open (neutral position)Choose FileNo file chosenDelete uploaded file2. Eyes closedChoose FileNo file chosenDelete uploaded file3. Looking upChoose FileNo file chosenDelete uploaded file4. Looking downChoose FileNo file chosenDelete uploaded fileVIDEO UPLOADUpload your 10-second blinking video (Max 7MB):(extensions mp4|mov |webm)Short video of opening and closing your eyes (blinking)Choose FileNo file chosenDelete uploaded fileALLERGIES & MEDICATIONSDo you have any known medical allergies?(e.g. Latex, Lidocaine/Xylocaine, medications)Please tick if you have any known sensitivity or allergy to the following: *Aloe VeraSulphurProgesteroneGlycolic AcidSunscreen (SPF Products)Vitamin C or E (Topical)Retin-A / RetinolnoneothersAny other cosmetic ingredients or skincare products that caused irritation or allergic reactions: *Please specify:List all medications you are currently taking(Including prescription, over-the-counter, supplements, herbs, aspirin, ibuprofen, etc.)Medical HistoryMedical Conditions *Do you currently have, or have you previously been diagnosed with, any of the following? Select all that apply.Thyroid disease or thyroid-related eye problemsHeart disease, heart failure or arrhythmiaBleeding or blood-clotting disorderDiabetesHigh blood pressureLow blood pressureStroke or other cerebrovascular conditionAsthma or another respiratory conditionAutoimmune conditionRosacea or another inflammatory skin conditionPemphigoid or another blistering skin conditionHerpes or recurring cold soresDepression, anxiety or another mental health conditionEye disease, impaired vision or persistent dry eyesNone of the aboveOtherPlease provide details:Any other relevant medical history, chronic conditions, current medications, or known sensitivities that may affect your treatment.Additional Medical InformationIs there anything else about your health, previous treatment or recovery history that our medical team should know?Your Declaration *I confirm that the information provided is true, accurate and complete. I understand that relevant health information may affect my treatment suitability and that submitting this form does not replace a medical consultation or guarantee treatment results.Terms & Conditions *I have read the Privacy Policy and consent to the processing of the personal, medical, photographic and video information submitted through this form.Privacy & Medical Data *I have read and agree to the terms and conditions.SubmitPlease do not fill in this field.
